Clinical, endoscopic and radiological assessment of patients with obstructed defecation: findings and management at a District General Hospital
DOI:
https://doi.org/10.18203/2349-2902.isj20212699Keywords:
Obstructed defecation, Rectocele, Intussusception, Proctogram, EndoscopyAbstract
Background: The aim of the study was to determine the diagnostic value of clinical, endoscopic and proctographic assessment as well as clinical outcomes in patients with obstructed defaecation (OD). The study also examined correlation between clinical/endoscopic findings and proctogram in the diagnosis of rectocele and intra-rectal intussusception (IRI).
Methods: Patients presenting with symptoms of OD between January-December 2018 were assessed with manual examination, endoscopy and defecation proctogram. Patients were followed for 2-3 years for clinical outcomes.
Results: There were 65 female (97.01%) and 2 male patients (2.98%), with an average age of 57.77 (34-88) years. Main indications were OD, altered bowels, faecal urgency and rectal bleeding. A total of 67 X-ray defecating proctograms and 77 endoscopies were performed. Main findings on clinico-endoscopic examination were IRI (44), rectocele (36) and haemorrhoids (21). Main findings on proctogram were rectocele (59), IRI (56) and enterocele (13). Endoscopic assessment showed sensitivity: 55.93%, specificity: 62.50% and accuracy: 56.72% in diagnosing rectocele when compared with the diagnostic confirmation on proctogram. Combining manual assessment with endoscopic findings improved sensitivity (76.27%) and accuracy (68.66%). Similar improvement was also noted in the sensitivity (61.40 to 66.67%), specificity (47 to 58%), and accuracy (53.73 to 58.21%) in diagnosing IRI when compared with the diagnostic confirmation on proctogram. Majority of the patients improved with conservative measures; however, surgical intervention was required in 13 patients.
Conclusions: Although manual examination enhances endoscopic assessment in diagnosing rectocele and IRI, proctogram is still required for objective assessment. Management of OD remains mainly conservative, with surgical intervention required in some patients.
References
Khaikin M, Wexner SD. Treatment strategies in obstructed defecation and fecal incontinence. World J Gastroenterol. 2006;12(20):3168-73.
Palsson OS, Whitehead W, Tornblom H, Sperber AD, Simren M. Prevalence of Rome IV Functional Bowel Disorders Among Adults in the United States, Canada, and the United Kingdom. Gastroenterology. 2020;158(5):1262-73.
Fabrizio AC, Alimi Y, Kumar AS. Methods of Evaluation of Anorectal Causes of Obstructed Defecation. Clin Colon Rectal Surg. 2017;30(1):46-56.
Forootan M, Darvishi M. Solitary rectal ulcer syndrome: A systematic review. Medicine. 2018;97(18):565.
Drossman DA, Hasler WL. Rome IV-Functional GI Disorders: Disorders of Gut-Brain Interaction. Gastroenterology. 2016;150(6):1257-61.
Regadas SM, Rodrigues LV, Furtado DC, Regadas FS, Olivia SFG, Regadas FFS, et al. The influence of age on posterior pelvic floor dysfunction in women with obstructed defecation syndrome. Tech Coloproctol. 2012;16(3):227-32.
Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology. 2006;130(5):1377-90.
Jain M, Baijal R, Srinivas M, Venkataraman J. Fecal evacuation disorders in anal fissure, hemorrhoids, and solitary rectal ulcer syndrome. Indian J Gastroenterol. 2019;38(2):173-7.
Kudish B, Blackwell S, Mcneeley SG, Bujold E, Kruger M, Hendrix SL, et al. Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol. 2006;195(3):749-54.
Kocaay AF, Oztuna D, Su FA, Elhan AH, Kuzu MA. Effects of Hysterectomy on Pelvic Floor Disorders: A Longitudinal Study. Dis Colon Rectum. 2017;60(3):303-10.
Badalian SS, Sagayan E, Simonyan H, Minassian VA, Isahakian A. The prevalence of pelvic floor disorders and degree of bother among women attending primary care clinics in Armenia. Eur J Obstet Gynecol Reprod Biol. 2020;246:106-12.
Tillou J, Poylin V. Functional Disorders: Slow-Transit Constipation. Clin Colon Rectal Surg. 2017;30(1):76-86.
Raahave D, Loud FB, Christensen E, Knudsen LL. Colectomy for refractory constipation. Scand J Gastroenterol. 2010;45(5):592-602.
Grossi U, Tanna GL, Heinrich H, Taylor SA, Knowles CH, Scott SM. Systematic review with meta-analysis: defecography should be a first-line diagnostic modality in patients with refractory constipation. Aliment Pharmacol Ther. 2018;48(11):1186-201.
Li M, Jiang T, Peng P, Yang X. MR Defecography in Assessing Functional Defecation Disorder: Diagnostic Value of the Defecation Phase in Detection of Dyssynergic Defecation and Pelvic Floor Prolapse in Females. Digestion. 2019;100(2):109-16.
Iacobellis F, Reginelli A, Berritto D, Gagliardi G, Laporta A, Brillantino A, et al. Pelvic floor dysfunctions: how to image patients?. Jpn J Radiol. 2020;38(1):47-63.
Prokesch RW, Breitenseher MJ, Kettenbach J, Herbst F, Maier A, Lechner G, Mahieu P. Assessment of chronic constipation: colon transit time versus defecography. Eur J Radiol. 1999;32(3):197-203.
Gruting IMA, Stankiewicz A, Kluivers K, Bin R, Blake H, Sultan AH, et al. Accuracy of Four Imaging Techniques for Diagnosis of Posterior Pelvic Floor Disorders. Obstet Gynecol. 2017;130(5):1017-24.
Bozkurt MA, Kocataş A, Karabulut M, Yırgın H, Kalaycı MU, Alış H. Two Etiological Reasons of Constipation: Anterior Rectocele and Internal Mucosal Intussusception. Indian J Surg. 2015;77(3):868-71.
Dvorkin LS, Gladman MA, Epstein J, Scott SM, Williams NS, Lunniss PJ. Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers. Br J Surg. 2005;92(7):866-72.
Karlbom U, Graf W, Nilsson S, Pahlman L. The accuracy of clinical examination in the diagnosis of rectal intussusception. Dis Colon Rectum. 2004;47(9):1533-8.
Dvorkin LS, Knowles CH, Scott SM, Williams NS, Lunniss PJ. Rectal intussusception: characterization of symptomatology. Dis Colon Rectum. 2005;48(4):824-31.
Hall GM, Shanmugan S, Nobel T, Paspulati R, Delaney CP, Reynolds HL, et al. Symptomatic rectocele: what are the indications for repair?. Am J Surg. 2014;207(3):375-9.
Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, et al. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol. 2012;18(36):4994-5013.
Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013;144(1):218-38.
Hicks CW, Weinstein M, Wakamatsu M, Savitt L, Pulliam S, Bordeianou L. In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort. Surgery. 2014;155(4):659-67.
Davis G, Chapple K, Brown SR. Ileostomy for chronic constipation: a good idea or just asking for more trouble?. Colorectal Dis. 2021;23(6):1474-9.
Obusez EC, Lian L, Kariv R, Burke CA, Shen B. Diagnostic yield of colonoscopy for constipation as the sole indication. Colorectal Dis. 2012;14(5):585-91.
Gupta M, Holub J, Knigge K, Eisen G. Constipation is not associated with an increased rate of findings on colonoscopy: results from a national endoscopy consortium. Endoscopy. 2010;42(3):208-12.
Perniola G, Shek C, Chong CC, Chew S, Cartmill J, Dietz HP. Defecation proctography and translabial ultrasound in the investigation of defecatory disorders. Ultrasound Obstet Gynecol. 2008;31(5):567-71.
Gabel M, Teshler M, Schechtman E, Zbar AP. Dynamic transperineal ultrasound vs. defecography in patients with evacuatory difficulty: a pilot study. Int J Colorectal Dis. 2004;19(1):60-7.
